A new study has turned the debate over physical therapy-versus-surgery for meniscal tears on its head—and even from that angle, the results again point to the validity of physical therapy as first-line option for treatment.

In an article published in JAMA (abstract only available for free), researchers from the Netherlands analyzed outcomes for adults aged 45-70 with nonobstructive meniscal tears, not by trying to find out whether physical therapy is better than surgery but by evaluating whether physical therapy is "noninferior" to surgery. The logic behind the approach is fairly simple: given that arthroscopic partial meniscectomy (APM) is 1 of the most frequently performed orthopedic surgeries, given that it comes with a hefty price tag ($4 billion annually in 2006), and given that it's, well, surgery, it would make sense that physical therapy would simply need to be no worse than surgery to qualify for consideration as a first-line treatment.

The study assigned 321 participants with nonobstructive meniscal tears to 1 of 2 groups: one that underwent APM, and another that participated in 16 30-minute sessions of physical therapy over 8 weeks that included "cardiovascular, coordination/balance, and closed kinetic chain strength exercises." Individuals who experienced locking of the knee, instability caused by an anterior or posterior cruciate ligament rupture, or severe osteoarthritis were not included in the study. Additionally, patients who had received prior knee surgery or whose BMI was higher than 35 were excluded.

To gauge improvement, researchers monitored outcomes from the International Knee Documentation Committee Subjective Knee Form (IKDC) a self-assessment measure that uses a 0-100 scale to rate knee function, symptoms, and ability to engage in physical activities. Assessments were taken at baseline, 3 months, 6 months, 12 months, and 24 months after randomization. As for the participants, both groups were similar, with a mean age of 58, 56% women, and comparable baseline knee function and pain during weight-bearing. Here's what researchers found:

Overall, the physical therapy group IKDC scores demonstrated noninferiority—defined by authors as average IKDC scores no more than 8 points apart—compared with the APM group. During the 24-month study period, knee function improved from 44.8 points to 71.5 points for the APM group, and from 46.5 points to 67.7 points for the physical therapy group.

While the score differences between physical therapy and APM showed physical therapy as noninferior at 3 months and 6 months, the gap widened at 12 months and 24 months. But those differences weren't enough to move physical therapy from an overall "noninferior" rating.

Participants who were obese tended to report higher improvement scores related to pain during weight-bearing than did their physical therapy counterparts. Other factors—location of the tear, education level of the participant, osteoarthritis severity, mechanical complaints, sex, and age—did not seem to significantly affect treatment outcomes.

"The results of this trial support the recommendations from the current guidelines that [physical therapy] may be considered an appropriate alternative to APMs as first-line therapy for patients with meniscal tears," authors write, adding that their study echoes the consensus that "APM should not be the first treatment in middle-aged and older patients with meniscal tears."

Authors of an accompanying editorial cast the results as yet another affirmation of physical therapy's effectiveness as a treatment for meniscal tears but wonder why "the orthopedic community [has been] slow to reduce APM."

The editorial authors speculate on several possible explanations, including "community norms" around the expected treatment, surgeons simply doing what they've always done, and the power of a volume-based health care environment that incentivizes more procedures. Change may only come, they write, when payers take a more informed approach to what is and isn't authorized—but even that change may be slow to happen until everyone can agree on treatment guidelines.

"To change clinical practice, it may be necessary to establish a consortium of all groups involved in the management of this knee condition—orthopedic surgeons, physiatrists, physical therapists, professional organizations, and insurance companies—to develop evidence-based treatment guidelines that each group can support," editorial authors write. "The guidelines should be focused on the best interests of the patients, rather than the clinicians, therapists, and other groups or entities who may gain from the different treatments."

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

While previous research has found that physical exercise decreases fall risk and improves mobility, researchers at the Universidad Autónoma de Madrid (UAM) in Spain wondered whether physical activity could reduce frailty-associated mortality risk. In their study, published in the Journal of the American Geriatrics Society, authors found that physical activity decreased mortality rates for healthy, prefrail, and frail adults over age 60.

Authors used data from a nationally representative sample of 3,896 community-dwelling individuals to explore any “separate and joint associations between physical activity and frailty” and all-cause and cardiovascular disease (CVD) mortality rates.

At baseline, in 2000–2001, researchers interviewed participants at home about their “leisure-time” physical activity: inactive, occasional, several times a month, or several times a week. They administered both the Fatigue, Resistance, Ambulation, Illness, and weight Loss (FRAIL) scale and 3 items from the 36-item Short-Form Health Survey (SF-36) to measure frailty, fatigue, resistance, ambulation, and weight loss. Participants also were asked whether they had been diagnosed with pneumonia, asthma or chronic bronchitis, hypertension, coronary heart disease, stroke, osteoarthritis or rheumatism, diabetes mellitus, depression under drug treatment, hip fracture, Parkinson disease, or cancer.

Based on their answers, participants were categorized as “robust,” “prefrail,” or “more frail.”

In 2014, authors determined that 1,801 total deaths had occurred, including 672 from cardiovascular disease.

Being physically active decreased all-cause mortality by 18% in robust, 28% in prefrail, and 39% in frail individuals.

Participants who were frail and inactive were 2.45 as likely as robust, physically active individuals to die of any cause.

Risk of all-cause and CVD mortality in frail, physically active individuals was similar to that of prefrail, inactive participants.

Prefrail, active individuals had all-cause and CVD mortality similar to robust, inactive participants.

This study, authors write, is the first to examine the effects of physical activity on mortality risk in frail and prefrail older adults. Authors speculate that physical activity contributes to longevity by helping to reduce chronic disease and falls and increase balance, strength, agility, and gait speed. This, they conclude, highlights the importance of future research on “the effectiveness of mobility programs to reduce mortality in frail older adults.”

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

CMS Wants Medicare Advantage to Increase Telehealth Coverage

In a proposed rule, the US Centers for Medicare and Medicaid Services (CMS) gives the green light to expand coverage for telehealth in Medicare Advantage (MA) plans. But when—and if—those changes would affect physical therapists (PTs) remains an open question.

The proposal from CMS would begin covering MA plans in 2020 within a range of areas, including changes for beneficiaries who are dually enrolled in Medicare and Medicaid, and tightened accountability within MA and Medicare Part D programs. But the provisions getting the most attention center on a CMS proposal to allow MA plans to treat telehealth benefits as basic benefits. It's a move prompted by the Bipartisan Budget Act (BBA) of 2018, which set the stage for wider use of telehealth under Medicare.

Under the proposed rule, MA plans would be allowed to offer what are known as "additional telehealth benefits" as basic benefits if they are available under Medicare Part B and deemed "clinically appropriate" for what CMS is calling "electronic exchange" services. Deciding what is and isn't "clinically appropriate" and thereby covered would be left to individual MA plans.

Additionally, the proposed rule would allow MA enrollees to engage in telehealth services in their homes or other locations, rather than requiring them to go to a specific facility. The range of technologies that would qualify is fairly broad under the proposal and includes secure messaging, store-and-forward technologies, telephone, videoconferencing, and other Internet-enabled technologies, as well as "evolving technologies."

"While MA plans have always been able to offer more telehealth services than are currently payable under original Medicare through supplemental benefits, this change in how such additional telehealth benefits are financed (that is, accounted for in payments to plans) makes it more likely that MA plans will offer them and that more enrollees will be able to use the benefits," according to a CMS press release.

Kara Gainer, APTA director of regulatory affairs, said that while the increased acceptance of telehealth in the proposed rule is a move in the right direction, CMS has yet to respond to the calls of APTA and other stakeholder groups to deliver more clarity on which providers it would expect to be included in any coverage of telehealth services.

"Implementation of the Bipartisan Budget Act provisions will no doubt increase patient access to needed care through electronic exchange, but many more details need to be worked out," Gainer said. "Physical therapists have an opportunity right now to make their voices heard by working with the Medicare Advantage plans they contract with and advocate for coverage of certain physical therapy services, and to explain how that coverage could save money and improve outcomes."

At the CMS level, Gainer also suggests that PTs and other stakeholders comment on the agency's proposals. APTA is reviewing the proposal and will provide comments to CMS by the December 31 deadline.

APTA member Dani Burt, PT, DPT, has a knack for turning inspiration into…more inspiration. Now a new APTA video helps to tell her story to the public.

As a teenager, Burt underwent an above-knee amputation as a result of injuries suffered in a motorcycle accident. During her recovery, she became inspired by the physical therapists (PTs) who worked with her and channeled that inspiration into the pursuit of her own career in physical therapy.

But that wasn't all: Burt's wholehearted embrace of the profession's emphasis on movement helped her to push herself as a surfer, ultimately earning Burt the title of World Adaptive Surfing Champion. These days, Burt hopes that her work as both a physical therapist and an adaptive sports champion will inspire others who face recovery challenges.

The short video from APTA follows Burt as she prepares for a session in the surf, and then tracks her as she rides the waves, with Burt saying that "the reality is that we're all healthier and happier when we move." You can find the video at MoveForwardPT.com, APTA's official consumer information website, which also offers a podcast featuring Burt. The video is also available on MoveForwardPT’s Facebook and Twitter accounts.

Dani Burt's video is part of an ongoing series from APTA demonstrating the benefits of physical therapy through personal stories. Be sure to check out videos on Charlie Plaskon, a triathelete who, in addition to being blind, worked through back pain with the help of physical therapy; Joanna Lohman, a professional soccer player, who credits physical therapy with helping her regain her identity after a knee injury; and Adrianne Haslett, a survivor of the Boston Marathon bombings who was able to pursue her love of dancing and run the Boston Marathon herself thanks to physical therapy.

CSM Delivers: Management and Leadership

APTA has a transformative vision for the physical therapy profession. Achieving that vision will require physical therapists (PTs) and physical therapist assistants (PTAs) to think beyond the clinician role and leverage their skills as managers—and change agents.

The 2019 APTA Combined Sections Meeting, set for January 23-26 in downtown Washington, DC, provides multiple forums for learning more about this crucial area of the profession. Check out these suggestions, and find other relevant programming by searching the CSM programming page.

Developing Your People: Preparing a Workforce for Value-Based Reimbursement
In a payment environment driven by patient outcomes and high-quality care, it's crucial to have a well-developed workforce with exceptional clinical, management, and leadership skills. Find out how an organization that serves older adults in over 200 skilled nursing and outpatient facilities in 14 states responded to that challenge by creating a culture that embraces ongoing development and a core set of essential clinical behaviors. Discussions will include the importance of frontline managers and manager development, the selection of a leadership development model, and a multistage rollout of a leadership program. Thursday, January 24, 8:00 am–10:00 am.

Success Strategies: Metrics That Matter for Private Practice Owners in 2019
As a private practice owner, you know you need to use your data better, but there's barely enough time to do everything else you have to do. So how can you get at the right data without getting overwhelmed? This session provides an up-close look at how owners of a private practice learned which metrics are key to the success of a practice and which are just background, and will include interactive components during which attendees decide which metrics they should track in their individual clinics and how to best communicate the importance of data and dashboards to their teams. Thursday, January 24, 11:00am–1:00 pm.

Global Volunteerism: From Organization to Boots on the Ground (3 sessions)
PTs and PTAs can choose from a vast number of international opportunities for volunteering, but it can be difficult to know which organizations are legitimate when trying to participate in leadership. Join in a 3-part discussion on opportunities for global leadership in education, national organizations, and medical volunteer trips. The speaker, president of the World Confederation for Physical Therapy, discusses the creation of this organization and the opportunities for leadership in the physical therapy profession on a global scale, and reflects on being a woman in a national position of leadership. Thursday, January 24, 8:00 am–10:00 am (part 1); 11:00 am–1:00 pm (part 2); 3:00 pm–5:00 pm (part 3).

CSM Delivers: Practice Tips

Staying engaged with the profession isn't just about tracking the latest research—it's also about learning new skills, techniques, and approaches.

The 2019 APTA Combined Sections Meeting, set for January 23-26 in downtown Washington, DC, offers sessions that will challenge you to learn something new that you can apply to your practice right now. Check out these suggestions, and find other relevant programming by searching the CSM programming page.

Get Rolling! Advanced Wheelchair Skills Training Empowers Optimized Mobility
This session is all about helping you understand, perform, and teach wheelchair skills to support wheelchairs users' independence, safety, and quality of life. The speakers will share guidance for optimal wheelchair selection and configuration, efficient education methods, and practical training techniques ranging from basic propulsion to advanced skills for extreme mobility and sports participation. In addition, you'll find out about an evidence-based approach for teaching wheelchair mobility, and get the latest on research and outcome measures. Friday, January 25, 11:00 am–1:00 pm.

Strategies to Optimize ICU-Based Rehabilitation
This session—led by an experienced interprofessional panel of stakeholders that includes clinicians, educators, and clinician-scientists—explores how to implement rehabilitation for those who are critically ill in intensive care. Get an update on key critical care literature that informs team management of this population, and explore implementation strategies to optimize clinical practice, including the importance of team communication and organization. Thursday, January 24, 8:00am–10:00 am.

The Heart of the Matter: Advocating for Physical Therapy in Oncology Survivorship
Physical therapists have a strong contribution to make in the developing field of oncology survivor care, particularly in the ways physical therapy can address cardiovascular and pulmonary dysfunction as a long-term effect of cancer and its treatment. Find out the considerations at play in providing physical therapy for the cancer survivor, and learn how to advocate for this important role in health care. Saturday, January 26, 11:00 am–1:00 pm.

APTA Working for You: Federal Advocacy Updates, October 2018

Advocacy for patients and the profession never stops. APTA helps its members by staying on top of changes and bringing the physical therapy profession's voice to the table on a wide range of payment and care-related issues. Here's a quick rundown of some of the latest news and APTA activities.

Recent Advocacy Wins

Diagnostic services furnished by PTs: APTA staff and 3 members of the Academy of Clinical Electrophysiology and Wound Management met with the Centers for Medicare and Medicaid Services (CMS) in January to discuss Medicare Administrative Contractors’ inconsistencies between the local coverage determinations and Medicare guidelines, specifically related to reimbursement for electromyography/nerve conduction studies by qualified physical therapists (PTs). As a result of the meeting and ongoing follow-up, CMS in early October clarified its policy that PTs should be fully paid for these services.

Use of pulse oximetry in the home: After APTA staff met with CMS to urge the agency to clarify whether a physician’s order is required when using pulse oximetry in the home, CMS issued a clarification. An additional clarification was issued by The Joint Commission.

APTA participates in a technical expert panel on postacute careIn late September, an APTA member and staff participated in a technical expert panel (TEP) convened by CMS and consultant RTI International to discuss development of a unified postacute care prospective payment system. APTA will continue to represent the profession on future postacute care TEPs. Check out recent Medicare Payment Advisory Commission Reports to Congress on the unified postacute care payment system, including the most recent June 2018 Report to Congress.

APTA provides public comments at HHS Pain Management Task Force MeetingAPTA staff provided public comments at the US Department of Health and Human Services (HHS) Pain Management Interagency Best Practices Task Force, highlighting the role of physical therapy in pain management.

CMS provider compliance meeting includes APTA representationAPTA staff participated in a meeting with CMS Program Integrity staff to discuss concerns and offer recommendations on improvements to the targeted probe-and-educate program, an initiative that provides personal help to providers interested in reducing claim denials and appeals. APTA will continue to represent the physical therapy profession at future provider compliance meetings.

* APTA nominee added to Medicare Evidence Development and Coverage Advisory Committee (MEDCAC) APTA member Meghan Warren, PT, PhD, recently was appointed to MACPAC after being nominated by the association.

Rehabilitation providers and agencies: APTA staff attended and presented on the Merit-based Incentive Payment System (MIPS) at the National Association of Rehabilitation Providers and Agencies 2018 Fall Conference.

Patient-centered care: APTA staff participated in the Agency for Healthcare Research and Quality Patient-Centered Clinical Decision Support Learning Network (PCCDS-LN) conference. The conference brought together diverse stakeholders from industry, government, and academia to learn about and discuss key issues in drafting a National Opioid Action Plan. Attendees also set an agenda for developing, disseminating, and applying PCCDS in other domains.

More Advocacy and Collaboration

National Institutes of Health (NIH): APTA member Julie Schwertfeger, PT, DPT, MBA, will represent APTA on the Disability Rehabilitation Research Coalition (DRRC) when it meets with NIH on October 23.

White House: APTA staff and members participated in a conference call with White House staff regarding the opioid epidemic and continued pain management collaboration, a follow-up to an in-person meeting held in August.

US Centers for Disease Control and Prevention (CDC): APTA staff participated in a conference call with the CDC to discuss ongoing collaboration on topics including the opioid crisis, traumatic brain injury, and falls prevention. Several immediate opportunities were identified.

CSM Delivers: Payment

You can be on the cutting edge when it comes to the latest research in physical therapy, you can have a deep understanding of the technologies available to enhance patient care, and you can be an expert on tests and measures, but at the end of the day, you have to get paid. And to do that, you must stay on top of a payment landscape that's changing rapidly—and dramatically.

The 2019 APTA Combined Sections Meeting, set for January 23-26 in downtown Washington, DC, offers multiple sessions all at 1 meeting that help clarify the sometimes-baffling ins and outs of payment, particularly around the Medicare and Medicaid systems. Check out these suggestions, and find other relevant programming by searching the CSM programming page.

Emerging Issues in Medicare: Payment Updates and Hot TopicsMedicare laws, rules, and policies are constantly changing and vary depending on the settings in which physical therapists (PTs) and physical therapist assistants (PTAs) practice. This session will explore the latest developments related to fee schedule payments, prospective payment systems, and payment reform. Find out how you can adapt your practice to keep pace with the changing laws and regulations. Friday, January 25, 8:00 am–10:00 am.

Emerging Issues in Medicare: Quality Programs and Alternative Payment ModelsPTs and PTAs are facing some of the most comprehensive changes to payment in years, thanks to new quality programs—most prominently the Merit-based Incentive Payment System (MIPS)—and alternative payment models under Medicare. Get up to speed on the shifts that come with implementing comprehensive health care reform legislation; alternative payment models; quality reporting programs, including MIPS; and more. Will there be challenges? Yes. But there are also opportunities worth exploring. Friday, January 25, 11:00 am–1:00 pm.

The Real World: How Therapists Can Thrive in Value-Based CareThe transition from fee-for-service to value-based payment is upon us, and this new payment model is here to stay. How do therapists, while still being paid fee-for-service, prepare for a successful shift and show that they are ready for value-based care? Presenters at this session will crack the code to success in value-based care with real-life case studies demonstrating what innovative practices are doing to achieve success in value-based payment arrangements today and capitalize on the opportunities of the future. They'll also review the steps PTs should take now to research, prepare for, and realize the opportunities available to them under value-based care arrangements. Saturday, January 29, 11:00 am–1:00 pm.

A Little Bit of This and a Little Bit of That: Billing and Payment in 2019Multiple billing and payment policies work in combination to affect your bottom line, but do you understand how they all fit together? This session looks at payment's component parts: how the monetary value of a CPT code is determined, the payment rates for the most common CPT codes billed under a physical therapy plan of care, elements of the multiple procedure payment reduction policy, the 2019 therapy dollar threshold and use of the KX modifier, and more. Also on the agenda: a discussion of Medicare's "8 minute rule" and the American Medical Association's definition of "substantial," and how they relate to billing determinations for individual visits. Thursday, January 24, 11:00 am–1:00 pm.

APTA Members: AMA Seeks Critical Input on New CPT Code Values

APTA members are being alerted to be on the lookout for 2 important surveys that APTA will disseminate for the American Medical Association (AMA) that will help to shape values for new current procedural terminology (CPT®) codes.

In the coming days, a random sampling of members will receive 1 of 2 surveys that focus on new CPT codes related to either dry needling or wound care. The surveys are designed to determine the “professional work” value and time involved in the physical therapist’s provision of the services identified by each of these codes.

"Professional work value" includes the mental effort and judgment, technical skill, and psychological stress involved in providing the service.APTA will submit the survey data to AMA’s Relative Value Scale Update Committee (RUC), a multispecialty committee whose purpose is to develop values for CPT codes based in part on survey data such as this. The RUC will make a recommendation to CMS for the professional work value of these newly developed codes.

If you receive an email requesting your participation in the survey: It is critically important to take the time to complete it. Your responses will be anonymous.

CSM Delivers: Moving Evidence Into Practice

The evidence base for physical therapy is growing stronger by the day, and patients, payers, and other stakeholders are taking notice. The next step: making the all-important connection between research evidence and real-world practice.

The 2019 APTA Combined Sections Meeting, set for January 23-26 in downtown Washington, DC, has no shortage of sessions focused on how physical therapists (PTs) and physical therapist assistants (PTAs) can bring that evidence into practice. Here are a few suggestions (and you can always find more by searching the CSM programming page).

The Ten Commandments for Fear of Falling: Evidence-Based Management StrategiesThis session provides evidence-based guidance for managing fear of falling in older adults in a variety of practice settings. Hear about the evidence for comprehensive interventions such as exercise, floor recovery, hip protection, cognitive-behavioral approaches, and functional mobility training as well as recent developments in emergency alert systems for older adults. The presenters will highlight community-based programs that target fear of falling reduction and fall prevention in older adults. Thursday, January 24, 8:00 am–10:00 am.

Spotlight on Research: Translating Rotator Cuff-Related Research Into PracticeTime to get interactive in a session that will present a series of rotator cuff-related abstracts accompanied by a 20-minute discussion focused on translating the evidence into practice, with plenty of opportunities for audience debate. The topics of this session can cover the spectrum of examination, rehabilitation, and treatment outcomes of subacromial pain pathologies, which may include areas such as rotator cuff tendinopathy, subacromial pain or impingement, tears, surgery, and postoperative management, depending on the research submitted to the section. Friday, January 25, 11:00 am–1:00 pm.

Aquatic Therapy for the Lower Extremity: Applying CPG Recommendations to PracticeIn this session, a board-certified orthopaedic clinical specialist, aquatic therapy specialist, and clinician will review the importance of incorporating recommendations and findings of clinical practice guidelines (CPGs) into practice. The focus will be on linking recommendations from 3 lower-extremity CPGs to aquatic therapy interventions, with plenty of discussion of aquatic therapy research as it relates to the clinical decision-making process. Saturday, January 29, 8:00 am–10:00 am.

CSM Delivers: Technology and Physical Therapy

Technology continues to advance at an exponential rate, but what does that mean for the profession? More important, what does it mean for patients in the here-and-now?

The 2019 APTA Combined Sections Meeting, set for January 23-26 in downtown Washington, DC, includes multiple sessions that go beyond the wow factor of technology and gets to practical applications in the clinic. Check out these suggestions, and find other relevant programming by searching the CSM programming page.

Why We Love AND Hate Our Robots: Implications for Everyday Clinical PracticeWhen it comes to the utilization and efficacy of robotic technology in rehabilitation of individuals with neurological diagnoses such as stroke and spinal cord injury, the research can be both encouraging and discouraging. What's behind the discrepancy in outcomes? Learn about the good and the not-so-good in robotic technology, implications for clinical practice, and when other evidence-based therapies are worth considering. Friday, January 25, 3:00 pm–5:00 pm.

Virtual Reality to Improve Mobility: Not Just Pretty PicturesWhile the availability, fidelity, and cost of virtual reality (VR) and gaming systems have improved dramatically, scientific evidence supporting their use has lagged. Here's your opportunity to glean information from several decades of combined speaker experience using VR and gaming technologies to scientifically study deficits associated with neurologic injury and disease. The session will include an overview of the range of currently available technologies, from complex and costly virtual reality systems to low-cost, easy-to-use clinic-friendly systems, as well as ideas from basic science and clinical experience that can be used to guide scientific study and clinical care. You'll also get tips on identifying the most appropriate VR or gaming technologies for your clinical applications. Thursday, January 24, 11:00 am–1:00 pm.

Moving Technology to Clinical Practice: Sensors and Real-World Activity AssessmentThe growth of sensor technology provides an opportunity for the physical therapist to capture patient functions over longer periods of time in their unstructured, natural environments. Find out why measuring activity outside the clinic is important, and how these remote measures reflect (or don't reflect) clinical measures. You'll also get updates on current research and examples of sensors clinicians can use now, accompanied by examples from pediatric and adult patient populations. Friday, January 25, 11:00 am–1:00 pm.

USBJI Young Investigators Program Accepting Applications for 2019 Program

Physical therapist investigators have an opportunity to receive guidance in getting their research funded and "other survival skills required for pursuing an academic career" through a program that connects them with experienced researcher-mentors.

The United States Bone and Joint Initiative (USBJI) and Bone and Joint Canada are now accepting applications for the Young Investigator Initiative, a career development and grant mentoring program. Investigators chosen for the program will attend 2 workshops 12 to 18 months apart and work with faculty between workshops to develop grant applications.

This grant mentoring workshop series is open to promising junior faculty, senior fellows, or postdoctoral researchers nominated by their department or division chairs. It also is open to senior fellows or residents who are doing research and have a faculty appointment in place or confirmed and have a commitment to protected time for research. Basic and clinical investigators, with or without training awards, are invited to apply.

Application requirements and more details can be found at the USBJI website. Deadline is January 15, 2019, to participate in the next workshop, April 26-28, 2019, in Rosemont, Illinois.

APTA Named 'Best in Business'

APTA is not only making a national impact—it's making a difference in the local community and helping its employees stay healthy. And now the association has earned a significant recognition for those efforts.

APTA was recently named "Best in Business" by the Alexandria, Virginia, Chamber of Commerce, an annual award that recognizes a local business that combines excellence in operations with a commitment to the Alexandria community. APTA originally was nominated for the award in the “large organization” category but took home the overall award among a field of 23 nominated businesses.

APTA’s submission highlighted the level of engagement among APTA's members, its solid financial operations, and its efforts in the ongoing battle against the opioid epidemic—particularly it's #ChoosePT opioid awareness campaign. At the local level, APTA engaged with the community through its cosponsorship of the Chamber's annual disability awareness awards and women in leadership initiatives.

Helping to strengthen APTA 's nomination were multiple initiatives stemming from its APTAServe program, a staff-driven effort that encourages local, national, and even international volunteerism by APTA employees. Those efforts have included blood drives, foodbank and school supply collections, and participation in the "Miracles Baseball League," a program that enables athletes with physical and intellectual disabilities to play baseball by pairing them with a volunteer. At a national level, APTA staff worked with volunteers to organize a Special Olympics FUNfitness screening and participated in "Shoes4Kids" drives. This year 2 APTA staff even traveled outside the US to engage in service by joining volunteers from MoveTogether to build, equip, and operationalize a new physical therapy clinic in San Pedro Sacatepequez, Guatemala.

"This award is a recognition of what APTA can do when we combine an energized and engaged membership with careful financial stewardship and a staff that embraces the transformative values of the physical therapy profession," said APTA CEO Justin Moore, PT, DPT. "We have a lot to celebrate and be proud of as we finish out 2018 and move toward the new year and next century for APTA."

The association's nomination also highlighted APTAFit, an employee health and wellness program that offers health-related services to staff, from healthy cooking workshops to individual consultations with health professionals to identify and achieve individual employee wellness goals.

CSM Delivers: Pain Science and the Challenge of Opioids

Addressing the opioid crisis means not only steering health care's approach to pain treatment away from drugs but fostering a better understanding of pain itself. There's no time to lose.

The 2019 APTA Combined Sections Meeting, set for January 23-26 in downtown Washington, DC, will deliver thought-provoking content on pain and opioids at a crucial time. Check out these suggestions, and find other relevant programming by searching the CSM programming page.

Pain Talks: Conversations With Pain Science Leaders on the Future of the Field
Join some of the most influential leaders in the field of pain science and rehabilitation for a discussion of the history of pain rehabilitation and how they personally became interested in the field, followed by an exchange on the current state of research on pain and its translation into clinical practice. The audience will be able to submit questions via text or email to the moderator for individual or panel discussion. Friday, January 25, 8:00 am–10:00 am.

Opioid Issues in Athletes
Opioid analgesics are the second most abused drug in the United States, with nearly half of students in seventh through twelfth grade having been prescribed these narcotics. These youth typically are athletes recovering from an injury or surgery—sometimes with devastating results. Find out about national efforts to address this issue, and hear the story of one athlete's journey from injury to addiction, and his long road back to health. Thursday, January 24, 8:00 am–10:00 am.

Remapping Neuroplasticity and Pain in the Clinic: A Case Series Session
There's growing evidence that graded motor imagery (GMI) can be used clinically to help desensitize a hypersensitive nervous system and provide hope for patients who are "too hot to handle." Body maps can be retrained within minutes through GMI, including normalizing laterality, motor imagery, mirror therapy, sensory discrimination, sensory integration, and more. Learn from published case studies and case series showcasing how brief GMI interventions can be readily applied in real-life clinics and result in immediate changes, thus accelerating recovery in people struggling with persistent pain. Saturday, January 26, 8:00 am–10:00 am.

Interprofessional Pain Management for Older Adults With Cognitive Impairment
Patients with cognitive impairment have difficulty or inability to communicate pain and discomfort because of cognitive, developmental, or physiologic issues, which is a major barrier to adequate pain assessment and achieving success in pain management interventions. This session is designed to help you respond to that challenge. You'll enhance your skills in recognizing pain in this population, identifying deficits and solutions through standardized tests and measures, and using interprofessional practice to improve outcomes. Saturday, January 26, 11:00 am–1:00 pm.

CSM Delivers: Students and Early-Career PTs and PTAs

You don't have to look very far to find an article that lists "physical therapy" as a hot, in-demand career. That's good news for students and newly minted physical therapists (PTs) and physical therapist assistants (PTAs), but it's also a challenge to the profession to ensure that those joining its ranks are prepared for and energized about their futures.

The 2019 APTA Combined Sections Meeting, set for January 23-26 in downtown Washington, DC, will offer several sessions of particular interest to students, educators, and others interested in preparing the next generation of professionals. Here are a few suggestions.

Future Momentum: Pushing Limits on Simulation to Maximize Student Preparation
What's the state of simulation-based education in preparing PT and PTA students for the dynamic, fast-paced arena of acute and critical care physical therapy? How can faculty and clinicians leverage this technology to maximize its potential? Experience lively discussion from an expert panel of acute care physical therapist academic faculty as they debate and challenge our existing evidence base regarding simulation-based education to prepare the next generation of PTs and PTAs. Friday, January 25, 8:00 am–10:00 am.

Competency-Based Education: Exploring Opportunities for Our Future
How well do our professional curricula and educational methods prepare our learners to meet current and future needs of patients, communities, and society? Competency-based education (CBE) theories have existed for decades but have only recently been applied to medical education, including the use of competencies, milestones, and entrustable professional activities, with a de-emphasis on the time required to demonstrate competence. This session will center on evaluation of ongoing development of CBE in medicine and its potential application to physical therapy. Friday, January 25, 11:00 am – 1:00 pm.

From Lightly Salted to Seasoned: Implementing Early Professional Development
The shift from student to PT or PTA can be dramatic for some. What can be done to maintain and even increase engagement in the profession during this critical time? Join panelists involved with the Florida Physical Therapy Association's Early Professional Special-Interest Group (SIG) to discuss their efforts to maintain membership engagement and facilitate the transition from new graduates to early-career professionals and further into association leadership. Thursday, January 24, 3:00 pm–5:00 pm.

The Good Stuff: Members and the Profession in the Media, October 2018

"The Good Stuff," is an occasional series that highlights recent media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

PT student makes Team USA:Faith Farley, SPT, earned a position on Team USA to compete in the 2018 functional fitness world championship. (HuntingtonNews.Net)

The right bike fit:Larry Meyer, PT, DPT, offers a motion-analysis system that incorporates a cyclist's technique into an evaluation designed to provide the best possible cycle-rider fit. (velonews)

Up to your neck in headaches:Jennifer Penrose, PT, DPT, explains the origins of cervicogenic headaches. (thurstontalk.com)

Cream of the crop: Brenau University (Georgia) students Jean-Marie Peters, SPT; Amber Holmes, SPT; and fellow BU PT students joined faculty members Robert Cantu, PT, EdD; and Tammy Buck, PT, DPT, in a unique program that brings students to migrant farming communities to provide care—and get a taste of the physical demands of migrant labor. (Brenau University Window online)

Quotable: "These dedicated people have been there on our Grace-Filled Journey every step of the way. They've cried with us during hard times and they've helped us celebrate the smallest milestones that most people wouldn't even think twice about. But most importantly to us, they never give up on Grace. Some days, Grace's biggest accomplishment is a smile, but that doesn't stop any of her therapists from working hard and encouraging her (and us) to celebrate all that life has to offer." – Mary Herschelman, on the physical therapists, speech-language pathologusts, and occupational therapists who have worked with her daughter Grace, who has infantile neuroaxonal dystrophy. (Hillsboro, Illinois, Daily News)

Study: Many Gaps Still Exist in Insurer Coverage of Nondrug Treatments for LBP

According to authors of a new study, physical therapy and occupational therapy to treat low back pain (LBP) frequently may be included in public and private insurer plans, but there's a lack of consistency in factors such as copays, referral requirements, prior authorization, and treatment limits. Coupled with a general lack of attention to many other nonpharmacological approaches to LBP, the inconsistencies create coverage gaps at a time when increased emphasis is being placed on nonopioid pain treatment, they write.

The study, published in JAMA Network Open, looked at 2017 data from 15 commercial, 15 Medicaid, and 15 Medicare Advantage (MA) health plans in 16 states selected to provide a cross section of relative wealth, geographic location, and other factors. In addition to the insurers studied—a sample that authors claim represents insurers of more than half of the nation's populace—researchers also interviewed 43 "senior medical and pharmacy health plan executives" to get their take on the use of, and barriers to, nonpharmacological treatments for LBP.

Researchers were interested in the degree to which insurers were covering nonpharmacological treatments for LBP and, if so, what restrictions they were placing on that use. It's an area in need of study, they say, given the current opioid crisis, the link between later opioid abuse and initial prescriptions of opioids to treat pain, and recommendations from the US Centers for Disease Control and Prevention (CDC) and others pushing for nonopioid approaches as first-line treatment for chronic noncancer pain.

The study focused on 5 nonpharmacological therapies for LBP across all plans: physical therapy, occupational therapy, chiropractic care, acupuncture, and therapeutic massage. Additionally, because the information was readily available through Medicaid, researchers added 6 more approaches to their review of Medicaid plans: transcutaneous electrical nerve stimulation (TENS), psychological interventions, steroid injections, facet injections, laminectomy, and discectomy. Here's what they found:

Physical therapy and occupational therapy fared well in terms of medical necessity.
Among both commercial insurers and MA, physical therapy and occupational therapy were almost always deemed a "medical necessity" and thus subject to coverage. Of the commercial insurer coverage policies reviewed, all included physical therapy, and all but 1 included occupational therapy.

But exactly how that physical therapy is covered? That's another matter.
Researchers found that when it comes to utilization management issues, not all plans are equal. Among the 15 commercial insurers studied, researchers found 1 instance of prior authorization requirements, 10 instances of limits put on visits to a physical therapist (PT), and 1 instance of a referral requirement. The prior authorization (PA) situation in MA is worse (a fact that APTA is working with other groups to change), with 5 of the 15 plans studied requiring PA, and 1 requiring a referral.

Copays can vary, too—sometimes by a lot.
In the MA plans studied, patient copays for physical therapy for LBP ranged from $32.50 to $40 per session; the range was $15 to $50 per session among the commercial payers.

Medicaid reflected the same general coverage patterns.
As in the commercial and MA study group, the Medicaid plans included in the research largely covered physical therapy and occupational therapy (14 of 15, with the remaining plan being "unclear or not found"). All other treatments were in the single digits, with the exception of TENS (10 plans covered) and chiropractic care (12 plans covered).

Are health plan execs on board with making it easier to access nonpharmacological pain treatments? Not exactly.
In their interviews with health plan executives, authors of the study found that "overall, informants indicated a low level of integration between coverage decision making for nonpharmacologic and pharmacologic therapies." Researchers noted that when the interviewees did mention "innovative strategies to combat the opioid epidemic," those strategies tended to center around improved formulary management of opioids, substance abuse treatment, and identification of opioid over-users and over-prescribers—"less so on innovations aimed at optimizing coverage and access to nonpharmacologic therapies for chronic pain," they write.

"The findings of this study support what we find on the ground with our members—namely, that while we have made progress in areas such as basic coverage and direct access, there's still much more work to be done to increase patient access to physical therapy and other nonopioid treatments," said Carmen Elliott, MS, APTA vice president of payment and practice management. "That's why we continue to engage with commercial payers, utilization management providers, and insurer interest groups to help them find a way to apply the evidence of physical therapy's effectiveness to their own policies."

Authors of the study echo that sentiment, writing that "despite a growing evidence base supporting the effectiveness and cost-effectiveness of many of the nonpharmacological treatments examined in our study, our findings depict inconsistent and often absent coverage for many of these treatments."

These inconsistencies present a challenge for patients, particularly those who are pursuing a multidisciplinary approach to treatment, they add.

"Treatment-based approaches can require a co-payment for each visit, in addition to costs associated with travel and missed work," authors write. "These issues are multiplied if a patient is taking a multipronged approach that incorporates multiple therapies for chronic pain. In addition, the wide variation in utilization management criteria…underscores the uncertainty that may exist around what constitutes an appropriate duration and intensity of treatment (eg, physical therapy) for chronic noncancer pain."

Authors of the study believe the way out of this dilemma may depend on establishing and promoting the evidence base for nonpharmacological pain treatment and—most important—for these treatments to be widely used by providers.

"Utilization management requirements were highly variable, which speaks to a need for evidence-based guidance regarding optimal use of these therapies, and standardized, comprehensive training for practitioners to effectively implement the evidence base into their practice," they write.

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

US House Members Echo APTA, Coalition Members' Call for Reduced Use of Prior Authorization by Medicare Advantage Plans

Calling the requirements "onerous and often unnecessary," more than 100 members of the US House of Representatives are pressing for improvements to the way prior authorization (PA) is used—and often misused—in Medicare Advantage (MA) plans. The lawmakers' call for changes echoes concerns voiced earlier this year by a coalition that includes APTA.

A bipartisan group of 103 legislators signed on to the October 10 letter to US Centers for Medicare and Medicaid Services (CMS) administrator Seema Verma, requesting that Verma direct the agency to conduct investigations around the use of prior authorization in MA, and to issue guidance "dissuading" MA plans from including requirements that include unnecessary barriers to care.

"It is our understanding that some plans require repetitive prior approvals for patients that are not based on evidence and may delay medically necessary care," the lawmakers write. "Many of these PA requirements are for services or procedures performed in accordance with an already-approved plan of care, as part of appropriate, ongoing therapy for chronic conditions, or for services with low PA denial rates."

The letter underscores the message delivered to Verma earlier this year by way of a letter from the Coalition to Preserve Rehabilitation (CPR), a group of 28 health provider, patient, and care professional and advocacy groups that includes APTA, the American Association of People with Disabilities, the American Occupational Therapy Association, the Brain Injury Association of America, the Epilepsy Foundation, the Michael J. Fox Foundation for Parkinson's Research, and the Paralyzed Veterans of America, among others.

The CPR letter suggests that CMS take its cue from the private insurance industry, which has been moving away from prior authorization, or at least investigate which prior authorization policies get in the way of medically necessary care. The coalition also recommends that CMS impose greater oversight of MA plans, with "stronger directives to MA plans to limit the use of prior authorization to services that are demonstrably overutilized."

The legislators' letter to Verma makes reference to the efforts of "key stakeholders"—presumably, CPR and other groups—and requests that "you and your staff engage with these organizations on additional opportunities to improve the PA process for all stakeholders."

APTA will continue to monitor this issue and share developments as they arise.

Given some of the major shifts in the Medicare payment landscape over the past few years, gaining an understanding of even the big-picture workings of the system can be a tall order. The Medicare Payment Advisory Commission (MedPAC) offers an updated resource that can help.

Now available for free download: MedPAC's latest version of "Payment Basics," a series of informational sheets that describe the need-to-know elements of 20 different Medicare payment systems. Areas covered include outpatient therapy, skilled nursing facilities, home health services, hospital acute inpatient services, and more. The newest version of the resource updates the 2015 edition.

Most information sheets provide background on how the system is organized and flowcharts for a visual representation of how that particular payment system works.

Quick facts from MedPAC Payment Basics: According to the MedPAC report on outpatient therapy, in 2016 Medicare spent $7.6 billion on outpatient therapy services, a 6% increase from 2015. Physical therapy services accounted for 72% of all spending in this area. In terms of settings, nursing facilities and physical therapy private practice clinics accounted for 71% of the spending, at 37% and 33%, respectively. Hospitals were next, at 16%.

New Report Looks at Link Between Surgery-Related Opioid Prescriptions, Later Opioid Abuse

Calling surgery "a long-ignored gateway to persistent opioid use, dependence, and addiction," the Plan Against Pain (PAP) has issued a new report that focuses on the relationship between opioid prescriptions for surgical procedures and later opioid dependence and abuse. The bottom line: though there are glimmers of hope, the overall outlook remains bleak, with 12% of patients who had a soft tissue or orthopedic operation in the past year reporting that they had become addicted or dependent on opioids after surgery. APTA's #ChoosePT opioid awareness campaign is a Selected Partner of PAP.

The report, which tracks surgery-related prescribing rates overall and as linked to 7 common surgical procedures—including total knee arthroplasty (TKA), total hip arthroplasty (THA), and rotator cuff repair—also breaks down statistics by demographic and geographic variables. Researchers relied on data from the National Prescription Audit, the PharMetrics Plus Database, and surveys of 500 US adults who had soft tissue or orthopedic surgery in the past 12 months. In addition, 200 surgeons were surveyed to assess, among other issues, their motivations for prescribing opioids. The study results were released on October 10 in conjunction with the "Summit for Solutions" event In Washington, D.C., attended by APTA.

Among the findings:

Overall opioid prescription numbers are declining, but state rates vary dramatically.
Nationally, in 2017, there were enough opioids prescribed to supply every person in the US with 32 pills, only a slight decrease from the 36-pill rate reported in 2016. And while every state in the country reported a drop in opioid use in 2017, those reductions varied widely, and the improvements for some states, while significant, only made a dire situation slightly better. Example: Alabama, the nation's top opioid-prescribing state, recorded a 10% decrease in opioid prescriptions between 2016 and 2017, but that only brought its opioid pills-per-resident ratio down to 65 pills for every resident—more than twice the national average.

Progress has been slow in reducing opioid prescription rates related to surgery.
Researchers found that among the 7 surgeries studied—TKA, THA, rotator cuff surgery, hysterectomy, hernia surgery, colectomy, and sleeve gastrectomy—the average number of opioid pills prescribed dropped, but only slightly, from 85 pills per patient to 82. Authors of the report speculate that the slow progress could be due in part to the level of pressure surgeons feel to prescribe more opioids then they feel are necessary—a pressure reported by 66% of surgeons surveyed.

The number of pills prescribed doesn't tell the whole story. The use of fewer pills at a higher potency also poses a risk—especially for orthopedic patients.
The study found that more than half of patients undergoing TKA, THA, and rotator cuff surgery were prescribed opioids of 50 or more morphine milligram equivalents (MMEs), more than double the 20 MME dosage recommended by the US Centers for Disease Control and Prevention (CDC). Nearly 1 in 4 orthopedic patients received prescriptions in excess of 90 MMEs per day, an amount that the CDC says poses a serious overdose risk.

Average rate of later opioid dependence and addiction among surgical patients hovered at 12%, but was higher for TKA patients.
Patients who received colectomy reported the highest incidence of later dependence, at 17%, but TKA patients weren't far behind, with a 15.2% rate of later misuse. Rotator cuff surgery and THA patients reported lower rates of later dependence, at 9.5% and 9.3% respectively. The 12% overall average is an increase from the 2017 study, which estimated the later dependence rate at 9%.

Women—and Millennial women in particular—are the most at-risk for becoming "newly persistent" opioid users after surgery.
Women were found to be 40% more likely than men to become "newly persistent" users—individuals who received opioid prescriptions 90 to 180 days post-discharge. Millennial women were found to be particularly at-risk, with more than 10% reporting persistent use, compared with 6% or Millennial men. The persistent use rate for Millennial women in the 2018 PAP study represents a 17% jump from the previous survey.

Authors of the report believe that until better guidelines are developed it's unlikely gains can be made in more careful use of opioids related to postsurgical pain. Although there has been some progress in this area, they write, more needs to be done to "relieve the pressure surgeons often feel to prescribe more opioids than patients actually need and help set patient expectations on the amount of opioids they'll be prescribed."

"[The lack of clear guidelines] has left surgeons mainly on their own in determining the appropriate quantity and strength of opioids needed to address their patients' pain," authors write. "As this report reveals, the absence of clear guidelines has led to tremendous variation in prescribing patterns and a great deal of overprescribing that can lead to persistent opioid use, addiction and dependence among patients, as well as unused pills that can be misused or abused by others."

It's World Arthritis Day: 5 Great Resources

World Arthritis Day, October 12, calls attention to a global problem in need of better public awareness: how exercise and education can reduce the impact of the disease. And there's little time to waste: according to a 2016 study, by 2040, an estimated 25% of Americans will have arthritis, and 1 in 10 will experience a disability related to the condition.

In honor of the day, here are 5 great resources that can help you develop community-based arthritis programs.

Understand the basics of evidence-based community arthritis programs.
What physical activity programs should you be looking for? Why recommend one program over another? What do the programs have in common? This quick reference guide from APTA helps you learn the lay of the land.

Find the best fit for you and your patients.
A program's target population, program length, class size, availability, and instructor requirements, can all be important factors in deciding which program would work best for you. APTA's decision aid can help narrow down the options.

Bring patients and other community members on-board with resources from MoveForwardPT.com.
APTA's consumer-focused website helps to explain the importance of arthritis programs, and provides an overview of some of the most highly regarded offerings from the US Centers for Disease Control and Prevention), the Arthritis Foundation, the Aquatic Exercise Association (, and others.

Get help from the experts.
APTA is a founding member of the US Bone and Joint Initiative (USBJI), a multidisciplinary education and advocacy group that provides extensive resources on arthritis and other musculoskeletal conditions. The USBJI's "Experts in Arthritis" webpage is loaded with videos and other public education resources that can help you help your patients and others understand the disease and the role that exercise can play in countering its effects.

Dive into a website that's all-things-arthritis.
As a member of the Osteoarthritis Action Alliance (OAAA), APTA helped to create some of the content and educational offerings available on this expansive site built for both consumers and clinicians. Resources include monthly "lunch and learn" webinars, information for providers, and research roundups.

[Editor's note: even more information on arthritis is available at PTNow, including tests and clinical guidelines.]

APTA Advocacy for EMG, Other Diagnostic Services Results in Payment Clarification from CMS

Good news for physical therapists (PTs) certified by the American Board of Physical Therapy Specialties in electrophysiologic physical therapy: the US Centers for Medicare and Medicaid Services (CMS) has stated in no uncertain terms that those PTs are permitted to perform certain diagnostic services without the need for physician supervision where those services are allowed by state law. The announcement was made after APTA and other stakeholders pressed the agency to clear the air in order to end payment reductions or outright denials to PTs providing the services.

According to the CMS statement, board-certified clinical specialists in electrophysiology physical therapy are qualified to provide services involving electromyography (EMG), nerve conduction velocity (NCV), and sensory evoked potentials (SEPs) without physician supervision, and should be paid for those services. It's a provision that's been around since 2001, according to CMS; however, the message wasn't always getting through to some Medicare Administrative Contractors and other payers, who would pay only for the technical component of the service, for some codes but not others, or nothing at all.

In its statement, CMS reminds stakeholders that it assigns a Physician Supervision Indicator (PSI) of “09” to its collection of PT-designated diagnostic services codes, making it clear that physician supervision is not required for the global and professional component codes of these services.

"APTA was concerned when it became clear to us that PTs weren't receiving appropriate recognition for these services, but grateful that the issue could be resolved through clear communications from CMS," said Kara Gainer, APTA director of regulatory affairs. "We hope that this statement will erase all doubts about whether a qualified PT can receive full payment for the delivery of services that have been permitted for nearly 2 decades."

From PTJ: Unwarranted Variation in Pelvic Floor Muscle Function Terminology an Obstacle to Advances in Treatment

Researchers use a wide variety of terms and definitions in published studies on pelvic floor muscle function (PFMF), according to authors of a new study in the October issue of PTJ (Physical Therapy). They say that it's this lack of standardized terminology, combined with too much focus on how to measure versus what to measure, that may be hindering “effective communication, data gathering, and advances in the evidence-based approach to women” with urinary incontinence (UI). [Editor's note: APTA members may access the full article for free through the "sign in via society site" link on the PTJ website.]

The study examined terms related to PFMF, as well as their "conceptual" and "operational" definitions, used in 64 cross-sectional studies in women with and without UI. Authors of the study were particularly interested in how definitions of terms (or the lack of definitions) impacted both the individual studies as well as the degree to which the studies could be compared with each other.

Authors began by clarifying what they meant by "conceptual" and "operational" definitions used in the studies they reviewed. For the PTJ study's authors, a conceptual definition involves a description of what needs to be measured—for example, a conceptual definition of the term strength is capacity of a muscle to generate force. An operational definition could be a procedure, such as vaginal manometry, as well as an explanation of how it was performed.

Authors identified 196 terms used in the various studies and grouped them into 61 categories—for example, "strength" was used as an umbrella term for 11 other terms such as "pelvic floor strength." The authors then looked at how well the studies managed terms and definitions. Here's what they found:

Only 29.7% of the studies included operational definitions of terms.

A single study might use different terms to refer to the same muscle function.

While "strength" was the most commonly researched muscle function, the term was conceptually defined in only 5 studies—in 3 different ways.

The operational definitions of "strength" included both dynamometry and manometry; however, several different scales were used, making it impossible to compare results.

“Concepts are the building blocks for all thinking,” write authors, who warn against “operationism”—focusing on how to measure variables as opposed to “what is relevant to be measured.”

“Once the concept being measured becomes synonymous to the measurement outcomes, even small changes in method produce a new concept,” researchers say. This leads to an increasing number of terms and definitions that make it difficult to gather and analyze data or generalize results. It also restricts a study’s results to its “particular methodology,” authors write.

The study results, say authors, “pose an urgent need to build and adopt a standardized terminology based on a sound theoretical framework encompassing the different disciplines, related areas, researchers and policy makers in order to increase understand¬ing of PFMF in women with UI and hopefully to provide higher quality of health care.”

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

The impact that loss of mobility can have on hospitalized older adults can reach far beyond the hospital stay, yet there is little consistency in the ways hospitals assess and promote movement, and almost no acknowledgement of mobility as an outcome measure. That needs to change, and soon, say authors of a new white paper advocating for a shift in "a hospital culture that does not value or prioritize mobility." APTA was among the organizations that participated in a peer review of the document, with member James Tompkins, PT, DPT, conducting the review.

The white paper, produced by the American Geriatric Society's (AGS) Quality and Performance Measurement Committee, describes the current state of mobility assessment in acute care settings as spotty at best, with a few hospitals conducting regular, validated mobility reviews with patients, and many others using inconsistent assessments or relying too much on hospital physical therapy departments to keep up with tests and measures that could be conducted by nurses. The assessment gaps, coupled with what researchers describe as a "focus on fall prevention at all costs," result in dramatic and potentially long-lasting losses in mobility in a population already at risk.

The lack of thorough and consistent assessments isn't necessarily surprising, given the general lack of attention paid to mobility as an outcome measure for acute care, according to authors of the white paper. "Nursing staff may be assessing mobility routinely and repeatedly, but they are not doing so in the standard or validated manner necessary for mobility quality measurement or intervention," authors write, adding that entities including the Joint Commission and the US Centers for Medicare and Medicaid Services (CMS) largely ignore mobility as an outcome measure.

To help fuel the needed changes, the white paper offers 7 recommendations:

Promote mobility assessment in acute care through "incentives for the use of standard, validated, mobility assessments" by CMS and other regulators

Advocate for more research funding for translational research in mobility assessment and intervention programs

Develop a consensus on standard methods to assess mobility "appropriate for acute care settings and clinically meaningful for providers and patients"

Minimize the burden of mobility measurement through, among other efforts, "optimizing workflow and documentation and minimizing redundancy by specifying the roles of various health care professionals such as nurses and physical therapists"

Evaluate the feasibility of a mobility quality measure for use by CMS

Reframe the current regulatory focus on falls in acute care to focus on safe mobility "in the face of little evidence of the effectiveness of strategies to prevent falls in acute care"

Develop resources for acute care providers available from AGS and other entities

One bright spot, according to the white paper authors, is that several standardized mobility assessments could fit the bill. Authors identified 6 assessments as especially promising, with most able to be administered by a nurse: the Activity Measure for Post-Acute Care 6-Clicks; the Banner Mobility Assessment Tool; the de Morton Mobility Index; the Hierarchical Assessment of Balance and Mobility; the Johns Hopkins Highest Level of Mobility assessment; the Minimum Data Set 3.0 version 1.14, Section G; and the Minimum Data Set 3.0 version 1.14, Section GG. [Editor's note: many of these assessments are available in APTA's PTNow online resource center.]

The end result, according to white paper authors: "We anticipate that routine mobility assessment will lead to a new paradigm in which stabilization of or improvement in mobility will be a universal indicator of high-quality hospital care."

On October 3 the US Senate passed the final version of the legislation by a 98-1 margin after the US House of Representatives passed the measure, 393-8. The bill is headed to the White House, where President Donald Trump is expected to sign it into law.

The legislation is wide-ranging, covering treatment for opioid addiction and use disorder, initiatives to help promote nonopioid alternatives to pain management, and stepped-up efforts to prevent foreign shipments of illegal opioids such as fentanyl, among other provisions. Changes included in the bill affect "almost every federal agency," according to a report in The Washington Post.

APTA strongly supported passage of the bill and worked with legislators and staff to advocate for policies that emphasize patient education and clinical research on pain and how it can be effectively managed without the overuse of opioids. The final version of the legislation echoes many of the recommendations included in an APTA white paper on the opioid crisis. Titled "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health," the document advocates for better public awareness efforts and improved benefit design for both public and private health plans.

"The bill now on its way to the White House represents a significant step in the right direction," said Kristina Weger, APTA congressional affairs senior specialist. "But there's much more work to be done—there are many provisions that direct agencies to begin reviews and studies on potential changes that we may not see for years. We need to continue our advocacy and outreach to help fight this crisis."

Increased screening for opioid use disorder and other substance use disorders during Medicare wellness and preventive care visits

Better education for Medicare beneficiaries on opioid use and pain management, including more information on nonopioid approaches and advice to discuss opioid use and pain management with their physicians

Direction that the US Department of Health and Human Services (HHS) submit a report to Congress on how to improve reimbursement and coverage for multidisciplinary, evidence-based nonopioid treatment for chronic pain, due within a year after the legislation is signed into law

Stepped-up guidance from HHS to Medicare-participating hospitals for reducing opioid use, developed in consultation with health care organizations, consumers, and other stakeholders

Establishment of an HHS technical expert panel to provide recommendations for best practices in surgical settings, including limits on the use of opioids in perioperative settings, with a report due within 1 year of the law's enactment

More information on the risks of opioid use and better coverage for nonopioid alternatives to pain management in Medicare Advantage plans and Medicare Part D prescription drug plans beginning in 2021

Expanded research overseen by the Interagency Pain Research Coordinating Committee to include investigations into best practices for the use of nonpharmacological pain treatments

Development of a demonstration program to test alternative pain management protocols in hospital emergency departments

APTA's involvement in addressing the opioid crisis dates back to late 2015 and includes the award-winning #ChoosePT public awareness campaign. The association is urging members to promote the profession's role in effective pain management during October as part of National Physical Therapy Month, and recently a physical therapy student-led "flash action strategy" focused on nonopioid pain management for an intensive 48-hour advocacy campaign with legislators on Capitol Hill. APTA also hosted a satellite media tour on the issue that resulted in more than 200 television and radio interviews across the country to an audience of more than 13.1 million, and in February hosted a Facebook Live event, "Beyond Opioids: Transforming Pain Management to Improve Health."

What's New at MoveForwardPT.com, Fall 2018

APTA's consumer information website, MoveForwardPT.com, is a continually expanding resource where patients learn about the many conditions and patient populations physical therapists (PTs) treat. The site includes everything from condition-based guides, podcasts, tip sheets, and videos, to our popular 'Find a PT' tool that patients can use to locate a member PT in their area. It's also home to APTA's national award-winning #ChoosePT opioid awareness campaign and toolkit.

Bottom line: MoveForwardPT.com is an evolving resource. Members are strongly encouraged to help APTA drive traffic to the site to expand awareness of the physical therapy profession.

Here are some recent additions to the site:

National Physical Therapy Month resources
October is National Physical Therapy Month, an opportunity to amplify our promotion of the benefits of physical therapy, and to make more people aware of APTA’s #ChoosePT campaign, the initiative aimed at raising awareness of physical therapy as a safe and effective alternative to opioids for the treatment of chronic pain conditions. Check out the #ChoosePT campaign toolkit for resources and ideas to help you highlight the ways physical therapy can address pain.

Move Forward Radio podcastsThe Risk of Cancer-Related Falls
September 20, 2018: Although falls are common among the elderly, cancer survivors have a higher prevalence of falls than do people who haven’t been treated for the disease.

The Benefits of Exercise on Brain Health
August 2, 2018: The benefits of being physically active are well known: it can enhance your cardiovascular system, control your weight, and strengthen your bones and muscles. But now there’s a growing body of evidence that being physically active benefits brain health and can help slow the decline in brain function that comes with age.

APTA-Backed Bill Protecting PTs Traveling With Sports Teams Likely to Become Law

APTA-supported legislation that protects physical therapists (PTs) and other health care providers who travel across state lines with a sports team is now just a presidential signature away from becoming law. Known as the Sports Medicine Licensure Clarity Act, the bill met with overwhelming bipartisan support in both the US House of Representatives and the Senate, and is on track to receive approval from President Donald Trump.

When it becomes law the legislation will provide added legal protections for sports medicine professionals when they're traveling with professional, high school, college, or national sports teams by extending the provider's "home state" professional liability insurance to any other state the team may visit. The law would apply to licensed health care professionals who travel with professional and collegiate teams or other athletes and teams sanctioned by a national governing body. The bill was introduced in the House by Reps Brett Guthrie (R-KY) and Cedric Richmond (D-LA), and in the Senate by Sens John Thune (R-SD) and Amy Klobuchar (D-MN).

"This is a big win for PTs, but an even bigger step forward in safeguarding the health of athletes," said Michael Matlack, APTA director of congressional affairs. "Once enacted, this law will help to support the realities of health care among teams that travel across state lines."

In its original form, the bill's coverage was restricted to only physicians and athletic trainers. Advocacy staff at APTA and representatives from the American Academy of Sports Physical Therapy (AASPT) worked closely with legislators and staff to ensure PTs and PTAs working under the supervision of a PT would also be included. Once the bill was introduced, APTA and section representatives worked in conjunction with other stakeholder groups to ensure support from as many legislators as possible. The final version of the legislation passed the House easily in 2017, and it received approval from the Senate by a 93-6 margin on October 3.

"We are grateful not only for the support of the legislators who introduced this bill, but for the sustained hard work of APTA members and members of the American Academy of Sports Physical Therapy to help achieve overwhelming backing in Congress," said Jennica Sims, APTA's congressional affairs and grassroots specialist. "Our success with this legislation shows what happens when individual member voices are part of a collaborative advocacy effort."

Celebrate National Physical Therapy Month: Support #ChoosePT

Recent data from the US Centers for Disease Control and Prevention revealed that more than 1 in 5 US adults live with chronic pain. Now's the time to help people understand how physical therapy can help.

October is National Physical Therapy Month (NPTM), an opportunity to amplify and promote the benefits of physical therapy, and to make more people aware of APTA’s #ChoosePT campaign, an initiative aimed at raising awareness of physical therapy as a safe and effective alternative to opioids for the treatment of chronic pain conditions. [Editor's note: those messages were emphasized as part of a recent national APTA satellite media tour that resulted in more than 200 television and radio interviews across the country to an audience of more than 13.1 million.]

“Those of us in the profession have long understood that physical therapy is a safe and effective alternative to opioids for the treatment of chronic pain conditions,” said APTA President Sharon L. Dunn, PT, PhD. “APTA offers many creative ways for us to bring that understanding to our communities at a crucial time. My hope is that we can apply our dedication to our profession to an even larger effort to address a crisis that is impacting lives across the country.”

In honor of NPTM, APTA has distributed a nationwide print and online feature article on the prevalence of low back pain and the many reasons patients and clients should choose physical therapy to safely manage their pain. In addition, APTA continues to add resources to its #ChoosePT online toolkit, a 1-stop shop for tips, tools, and information about the risks of opioids and how physical therapy can help with pain management.

Getting involved in NPTM is easy. Here are 5 ways to share the #ChoosePT message this month and all year long:

1. Access handouts, social media graphics, and other resources from the #ChoosePT toolkit.
APTA’s award-winning #ChoosePT campaign has reached millions to promote treatment by physical therapists (PTs) for pain management. Whether you’re participating in a community event or sharing resources online, the #ChoosePT campaign toolkit has what you need.

2. Take the #ChoosePT message somewhere fun—and take a picture!
We want to know how you’re celebrating NPTM. Go find a landmark, a park, a mountaintop, and anywhere in between, and take a photo demonstrating your #ChoosePT pride. Post them to social media using the #ChoosePT hashtag or email them to public-relations@apta.org. We’ll be sharing our favorites throughout the month.

3. Get the #ChoosePT TV and radio public service announcement aired in your area.
APTA’s latest public service announcement has already reached more than 50 million Americans. Help us grow that by volunteering to contact your local TV and radio stations. Email public-relations@apta.org to volunteer and APTA staff will provide you with step-by-step instructions.

4. Promote MoveForwardPT.com.
APTA’s official consumer information site serves millions of Americans each year. From symptoms and conditions guides to patient stories, podcasts, and tips pages, MoveForwardPT.com is your go-to resource for showing all the ways PTs and physical therapist assistants transform lives.

5. Update your Find a PT profile.
National Physical Therapy Month activities lead to an increase in traffic to Find a PT, APTA’s national database of practicing clinicians. Make sure to update or activate your profile so consumers and other health care professionals can easily find you.

One of the first school therapists in Washington State and a lifelong advocate for persons with disabilities, physical therapist (PT) pioneer Jeanne Fischer, PT, died on September 4, 2018, in Tacoma, Washington. She was 94.

A graduate of the physical therapist educational program at the University of Kansas in 1948, Fischer began her at St Luke’s Hospital in Kansas City, Missouri. In 1958, she began a 31-year tenure as a PT for the Tacoma, Washington, School District while married and raising 3 young daughters. It was during her years as a school-based PT that Fischer gained her reputation as an outstanding mentor and advocate.

Fischer was a founding member of the former Section on Pediatrics (now the Academy of Pediatric Physical Therapy), serving as the group's vice chair from 1979 to 1983. She also served as head of the Pediatric Specialty Council responsible for the development of the APTA specialty certification in pediatric physical therapy. In 1981, she was honored with the section’s G.E. (Bud) De Haven Award for extraordinary service and, in 1984, received a certificate of appreciation for outstanding service as the pediatric representative to APTA’s initial Task Force in Clinical Specialization.

The academy further acknowledged Fischer's commitment to mentorship when it created the Jeanne Fischer Distinguished Mentorship Award in 1993. The award, bestowed annually at the APTA Combined Sections Meeting, recognizes an academy member who has demonstrated sustained, altruistic mentorship beyond that expected within their regular employment.

In addition to honors from the academy, Fischer received numerous national and state awards. APTA recognized Fischer with both a Lucy Blair Service Award and Henry O. and Florence Kendall Award. Fischer received a Distinguished Service Award from the Washington State Physical Therapy Association and the William Duncan Award from United Cerebral Palsy of Washington. In 1996, APTA honored Fischer for 50 years of membership and service, calling her a pioneer in the profession.

From PT in Motion Magazine: Moving Away From Opioids

Health experts, federal agencies, and national organizations such as APTA have been sending a clear message that providers and patients should first consider nonopioid treatments such as physical therapy for chronic pain. But has it made a difference?

Yes, according to Alice Bell, PT, DPT, APTA senior payment specialist, who represented APTA on the National Quality Forum’s “opioid stewardship action team” earlier this year. She tells PT in Motion magazine that "Across the profession, we're seeing more and more patients who are accessing physical therapy before opioids are prescribed, or who've been on opioids but realize they aren't helping to treat or manage their underlying conditions."

“Moving Away From Opioid Reliance” is featured in the October issue of PT in Motion magazine and is open to all viewers—pass it along to nonmember colleagues to show them one of the benefits of belonging to APTA. Printed editions of the magazine are mailed to all members who have not opted out; digital versions are available online to members.

Physical therapist assistants (PTAs) play a crucial role on the care delivery team, and APTA is bringing that message to multiple stakeholders. Here's a rundown of some of the latest happenings in the association's advocacy for PTAs.

Now available: an estimated timeline for PTA inclusion in TRICARE.
In December 2017, President Trump signed a National Defense Authorization Act that included a change long advocated by APTA: inclusion of PTAs in the TRICARE program used throughout the Department of Defense (DoD) health care system. However, like many federal-level policy changes, implementation wasn't immediate, and it wasn't clear just how or when this change would happen.

APTA can now shed a little light on the process. Informed by discussions with DoD representatives and others, the association developed a timeline that provides a sense of just how long it might take for the TRICARE policy change to take effect (scroll down to "TRICARE" header).

The process hinges on when the proposed rule is released to the US Office of Management and Budget (OMB) for review—possibly this fall or spring of 2019. That release triggers a timeline for a series of steps that involve publication in the Federal Register, a public comment period, and agency reviews. Because the OMB release hasn't happened yet, and because various actions could take place before their deadlines, it's hard to pin down a specific date for the end of the process. The only firm date associated with the change is that it has to happen by 2021. The APTA chart helps provide a sense of the length of different steps of the process and helps visitors track progress. APTA will provide updates on the regulatory process, and alert members once the public comment period on the proposed rule has begun. In the interim, APTA is working with congressional allies to keep the pressure on for an expedited process once the proposed rule is released [Editor's note: recently, Rep Rob Wittman (R-VA) submitted a letter to DoD asking when OMB will receive the proposed rule now that 9 months have passed since the legislation was signed into law.]

Yes, PTAs are included in TriWest.
APTA also has received clarification that TriWest, the entity that oversees administration of the Department of Veterans Affairs "Veterans Choice" health care program in specific regions of the country, does in fact allow for treatment by PTAs. Unlike the TRICARE change, the TriWest statement describes the current environment and is not dependent on any wait for adoption of new rules.

APTA continues to push back on US Centers for Medicare and Medicaid Services (CMS) plans to adjust payment provided "in part" by a PTA.
CMS is bound by law to establish PTA and occupational therapy assistant (OTA) coding modifiers that will go into effect on January 1, 2020 and include a Medicare payment differential beginning in 2022. The problem, in APTA's view, is that the CMS approach—to assign the modifier to services provided "in part" by a PTA or OTA—could significantly impact patient access to care, particularly in rural and underserved areas. The CMS approach is mentioned in its proposed 2019 physician fee schedule.

APTA made its position clear in comments on the fee schedule, and encouraged members and other stakeholders to provide individual comments critical of the "in part" approach. Additionally, association representatives and representatives from the American Occupational Therapy Association (AOTA) met with CMS representatives in person to discuss the issue. At the same time, APTA and AOTA are advocating on Capitol Hill for Congress to commission a US Government Accountability Office study to examine how access to physical therapy and occupational therapy will be impacted by the pending 2022 Medicare payment differential.

APTA and Laurel Road now offer an option for PTA student loan debt refinancing.News from the APTA Financial Solutions Center: PTAs now have another option for reducing their student loan debt. APTA has expanded its partnership with Laurel Road, a national lending and banking company, to include student loan refinancing for PTAs. Under the new offering, PTAs who have worked for at least 1 year in the profession are eligible to apply to refinance their student loans to a lower rate.

"It's important to be a member of APTA and engaged on these critical issues that impact PTAs, the profession, and the patients we serve," said David Harris, PTA, BS, MBA, chief delegate of the PTA Caucus. "We all have a professional responsibility to do everything in our power to provide access to all those in need of physical therapy, and our APTA membership gives us all a voice on the national level. Advocacy strengthens with every membership voice."

A physical therapist (PT) and physical therapist assistant (PTA) student-led "flash action strategy" held September 26-27 focused on bringing a clear message to Capitol Hill: physical therapy plays an important role in effective, nondrug management of pain and shouldn't be left out of any approaches to addressing the nation's opioid crisis.

It was a message that came through loud and clear—to the tune of nearly 7,000 contacts with lawmakers and their staff.

Despite busy semesters, students from multiple PT and PTA programs took time to participate in the nationwide effort, primarily using social media to concentrate their efforts during a 48-hour window of intense messaging. In addition to contact from students, physical therapists, and physical therapist assistants, the push included 176 contacts from physical therapy patients using APTA's Patient Advocacy Center.

"The excitement and focused participation during this flash action campaign shows a tremendous level of engagement and commitment to the profession among APTA's student members," said Jennica Sims, APTA's congressional affairs and grassroots specialist. "It's inspiring to see the next generation of the profession taking the lead in this grassroots effort."

PT and PTA students will bring their energy and excitement to the upcoming APTA National Student Conclave, set for October 11-13 in Providence, Rhode Island.